Original Article
Crossed Cerebellar Diaschisis Detected by Arterial Spin-Labeled Perfusion Magnetic Resonance Imaging in Subacute Ischemic Stroke

https://doi.org/10.1016/j.jstrokecerebrovasdis.2014.05.009Get rights and content

Background

Crossed cerebellar diaschisis (CCD) was a common radiological phenomenon manifested as reduced blood flow and metabolism in the cerebellar hemisphere contralateral to a supratentorial cerebral lesion. The hypoperfusion and hypometabolism in the contralateral cerebellum in CCD was traditionally detected by positron emission tomography (PET) and single-photon emission computed tomography (SPECT). The present prospective study aimed to assess the detection of CCD in subacute stage ischemic stroke by arterial spin-labeling (ASL) perfusion technique with a 3.0-T magnetic resonance imaging (MRI) scanner.

Methods

ASL images were obtained from 46 patients with supratentorial ischemic stroke at subacute stage. Regional cerebral blood flow values in the cerebellar hemispheres were measured on a region of interest basis.

Results

Twenty-four of 46 (52%) patients showed CCD phenomenon by ASL-MRI method, which was in line with the PET/SPECT series. Infarctions in basal ganglia areas are prone to cause CCD.

Conclusions

With advantages in easy acquisition and no radiation, ASL-MRI seems to be an ideal tool for the detection and follow-up of CCD.

Introduction

Crossed cerebellar diaschisis (CCD) is a common radiological phenomenon manifested as reduced blood flow and glucose metabolism in the cerebellar hemisphere contralateral to a supratentorial cerebral lesion.1, 2 Although mostly seen in cerebral stroke, CCD has been reported in other clinical conditions such as status epilepticus, glioma, encephalitis, and cerebral ischemia–reperfusion process.3, 4, 5, 6 CCD can be long lasting as seen in many ischemic stroke cases or transient and reversible as seen in status epilepticus. It is considered as a continuum between potentially reversible hypoperfusion status and irreversible degeneration depending on the reversal of abnormal supratentorial cerebral lesion. The interruption of the cerebropontine-cerebellar pathway is thought to be the underlying cause of CCD.

Originally considered as merely a neuroradiological phenomenon, recent findings suggested CCD as an important prognostic indicator of stroke recovery and treatment response.7, 8, 9 There is also increasing evidence for the cerebellar involvement in cognitive function notably in executive control, verbal memory, and language.10 A hypothesis that disrupted cerebellar function by CCD after stroke may result in vascular cognitive impairment in the long run has been conceived.11 Thus, it is necessary to find an easy, noninvasive, and widely available imaging method for the detection and intensive study of CCD.

The hypoperfusion and hypometabolism in the contralateral cerebellum in CCD was traditionally detected by positron emission tomography (PET) or single-photon emission computed tomography (SPECT). A study using perfusion-weighted magnetic resonance imaging (PWI) found PWI could detect CCD but with a reduced sensitivity compared with the previous findings by PET/SPECT.12 Another similar study found 1.5 T PWI-MRI was not suited to detect CCD after stroke because of poor accuracy in comparison with PET.13

Arterial spin labeling (ASL) is a novel noninvasive MRI-based technique for quantitative cerebral blood flow (CBF) measurement. Briefly, ASL-MRI takes advantage of magnetically labeled blood water as an endogenous tracer for quantification of brain perfusion. Unlike PET and SPECT, ASL-MRI was more available and less expensive without exposure to ionizing radiation. These make ASL perfusion technique being rigorously explored in many different disease conditions and has gained success in stroke and neurodegenerative conditions.14

Considering the previously mentioned evidence, the present study aimed to assess the detection of CCD in subacute stage ischemic stroke by ASL-MRI.

Section snippets

Subjects

Forty-six patients (34 male and 12 female) with their first-ever acute ischemic stroke were enrolled by the Department of Neurology in People's Hospital of Zhengzhou University. On admission, the diagnosis of acute hemispheric ischemic stroke was made according to the symptoms and signs and MRI findings (series: T1WI, T2WI, diffusion weighted imaging [DWI], fluid attenuated inversion recovery [FLAIR], magnetic resonance angiography [MRA]). Patients who met the following criteria received the

Results

Of 46 patients with supratentorial infarcts, 24 patients (52.2%) exhibited CCD. None of the 24 patients with CCD showed cerebellar signs of dysfunction. There was no significant difference in mean age between the CCD(+) and CCD(−) groups (55.71 ± 10.41 years, 58.18 ± 10.53 years, respectively; P = .43). The mean duration from stroke onset to ASL imaging was 11.75 ± 4.52 days for CCD(+) group and 9.91 ± 3.88 days for CCD(−) group (no significant difference between groups; P = .15). CCD(+) and

Discussion

As a common phenomenon recognized long ago, several aspects in CCD have not yet been fully understood. Earlier studies in stroke patients mainly concentrated on CCD phenomenon in the acute and subacute stage. Thus, the influence of clinical status on the degree of CCD and CCD on disease outcome in the long run was still unclear. One reason is that CCD was traditionally detected by PET or SPECT technique as a golden standard, which make the longitudinal follow-up a difficulty. The main objective

Acknowledgment

The authors express their gratitude to Dr Wei Chen (Department of Neurology, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, People's Republic of China.) for his generous help in the study design.

References (27)

  • G. Szilágyi et al.

    Correlation between crossed cerebellar diaschisis and clinical neurological scales

    Acta Neurol Scand

    (2012)
  • M. Takasawa et al.

    Prognostic value of subacute crossed cerebellar diaschisis: single-photon emission CT study in patients with middle cerebral artery territory infarct

    AJNR Am J Neuroradiol

    (2002)
  • D. Timmann et al.

    Cerebellar contributions to cognitive functions: a progress report after two decades of research

    Cerebellum

    (2007)
  • Cited by (39)

    • Lateralization of the crossed cerebellar diaschisis-associated metabolic connectivities in cortico-ponto-cerebellar and cortico-rubral pathways

      2022, NeuroImage
      Citation Excerpt :

      This tendency was not observed in control group, while the positive correlation in neurological activity was only found between the ipsilateral neostriatum and contralateral cerebellar cortex in CCD- group. Several studies have manifested that lesions in the regions of striatum and thalamus were prone to induce the occurrence of CCD (Chen et al., 2014; Noguchi et al., 2015; Sin et al., 2018). Adjacent internal capsule area with densely packed descending nerve fibers may also be implicated, inhibiting the downstream cortico-ponto-cerebellar tract.

    • Crossed Cerebellar Diaschisis Has an Adverse Effect on Functional Outcome in the Subacute Rehabilitation Phase of Stroke: A Case-Control Study

      2019, Archives of Physical Medicine and Rehabilitation
      Citation Excerpt :

      Any stroke lesion disrupting this pathway may result in CCD. Previous studies have reported a higher incidence of CCD in patients with a stroke in the fronto-temporo-parietal area and deep MCA territory involving the internal capsule and lentiform nucleus, which is consistent with our results.3,11,15 In this study, patients with CCD showed more severe functional impairments compared to those without CCD.

    • Detection of subthreshold atrophy in crossed cerebellar degeneration via two-compartment mathematical modeling of cell density in DWI: A proof of concept study

      2018, Medical Hypotheses
      Citation Excerpt :

      Since then, MRI and CT perfusion studies have demonstrated mixed results for detection of CCD when compared to PET [14–16]. Most recently, arterial spin-labeling MRI has been very promising in detection of CCD [17–19], however, this technique is not routinely performed at every clinical institution and remains limited in its signal-to-noise ratio and susceptibility to artifacts. Our approach offers the advantage of applicability to DWI, which is routinely obtained in most clinical settings.

    • Crossed cerebellar diaschisis in post-treatment glioma patients: A comparative study of arterial spin labelling and dynamic susceptibility contrast

      2018, European Journal of Radiology
      Citation Excerpt :

      Several studies had investigated the relationship between the supratentorial lesion location and the presence of CCD. Postcentral cortex, basal ganglia, corona radiata, anterior frontal cortex, thalamus, and even left-sided infarction [2,3,23–26] have been reported to be associated with the presence of CCD. Our study found that the presence of CCD correlated with lesions involving the corona radiata, basal ganglia, and insula.

    View all citing articles on Scopus

    S.C. and M.G. contributed equally to the work.

    This research was supported by State Key Clinical Specialty Construction Project (2012) and the National Natural Science Fund (81271534).

    View full text